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Effective: August 1, 2007 |
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24.15ar2 - Health Care Expenses (Archive) |
Archived: December 1, 2007 |
To be eligible for Medical Assistance (MA), clients may reduce excess net countable income by deducting health care expenses. This section will provide information regarding the type of health care expenses that are allowed and the client responsibilities for reporting and verifying those health care expenses.
Reporting Health Care Expenses.
Whose Health Care Expenses are Allowed?
Allowable Health Care Expenses.
Types of Health Care Expenses.
Health Care Expenses Not Allowed.
Reporting Health Care Expenses
All health care expenses must be reported and verified.
Note: See Spenddown Adjustments when a client reports health care expenses after the date of spenddown approval.
If the client’s total net countable income is over the appropriate federal poverty guideline (FPG), follow up with the client and determine if any household members have paid or unpaid health care expenses.
Send a Medical Expenses form (DHS-1844), along with a Verification Request Form – B (DHS-2919B), to MA clients who have a spenddown and need to report their health care expenses.
l This form is electronically fillable if the client chooses to access the form via the internet.
l DHS does not include this form in any mailings.
Apply health care expenses incurred by the following people to a client’s spenddown:
l Client.
l Client’s spouse if the spouse’s income is used to determine the client’s eligibility.
Example:
William receives MA services through the CADI waiver. He lives with his wife, but he is a household size of one and her income is not used to determine his eligibility.
Action:
Only William’s medical expenses can be applied to his spenddown.
l Client’s legal dependents if they are included in the client’s household size or would have been included when the bills were incurred.
Example:
Sherronda applies for MA for herself and her 16-year-old daughter Toya. She has a two-year-old unpaid medical bill for her 19-year-old daughter Shantay, who lived with her when the bill was incurred but has since moved out. Sherronda remains responsible for the bill.
Action:
Sherronda can apply the old bill to her spenddown because Shantay would have been included in her household size when the bill was incurred.
l Client’s siblings, half-siblings, and step-siblings who are included in the client's household size.
l Parents or stepparents who live with the client if their income is actually used to determine the client’s eligibility or they are included in the client's household size.
Note: The family members described above do not have to be applying or eligible for MA for themselves for the client to use their health care expenses to meet a spenddown.
Example:
Nicole, age 20, applies for MA and has a spenddown. She lives with her parents who are not applying. Nicole is not emancipated and her parents' income is deemed to her.
Action:
Nicole’s health care expenses and those of her parents may be used to meet Nicole’s spenddown amount.
See Associated Recipients for information on how submitted medical claims may be applied to more than one household member’s spenddown.
Allowable Health Care Expenses
Health care expenses may include either:
l Paid or unpaid bills incurred in the current certification period.
l Unpaid bills incurred prior to the current certification period.
The portion of a bill used to meet a previous spenddown cannot be used again in future spenddown calculations, unless the entire certification period was denied.
Health care expenses incurred before the spenddown satisfaction date are not eligible for MA payment; the client will remain responsible for those bills.
Use the verified net health care expense.
Health care expenses include but are not limited to:
l Health insurance premiums.
l Doctors visits.
l Dentist visits.
l Chiropractors.
l Co-payments.
l Prescription drugs.
l Tests and X-rays.
l Hospital and nursing care.
l Home nursing care.
l Eyeglasses.
l Hearing aids.
l Dentures.
l Medical supplies, such as wheelchairs.
l Therapy, such as speech therapy or occupational therapy.
l Transportation for medical care, such as car, taxi, bus or ambulance.
Example:
Laurie is applying for MA in May and is requesting one month of retroactive coverage. She has a six-month spenddown amount of $500. Laurie has the following verified health care expenses:
|
Day of Month |
Expense |
Amount |
Status |
|
January 3 |
doctor's visit |
$200 |
Unpaid |
|
January 12 |
doctor's visit |
$150 |
Paid |
|
April 3 |
doctor's visit |
$150 |
Unpaid |
|
April 3 |
lab tests |
$90 |
Paid |
|
April 3 |
pharmacy (ongoing monthly cost) |
$120 |
Unpaid |
|
April 15 |
doctor's visit |
$150 |
Unpaid |
Action:
Laurie’s health care expenses exceed her spenddown amount. She is eligible for MA.
Only the January 12 expense will not be used to meet the spenddown because it was incurred prior to the certification period and it has already been paid.
Health care expenses were applied to her spenddown in the following way:
|
Day of Month |
Expense |
Amount |
Status |
Spenddown Amount ($500) |
|
January 3 |
doctor's visit |
$200 |
Unpaid |
- $200 |
|
April 3 |
lab tests |
$90 |
Paid |
- $90 |
|
April 3 |
doctor's visit |
$150 |
Unpaid |
- $150 |
|
April 3 |
pharmacy |
$120 |
Unpaid |
- $60 |
Laurie’s satisfaction date, the date she exceeds the spenddown amount, is April 3rd.
Laurie’s recipient amount, the amount of health care expenses she is responsible for on the satisfaction date, is $210.
n Laurie will remain responsible for the January 3 bill, and the April 3 lab test bill (which is already paid).
n The unpaid April 3 bills will need to be submitted to DHS claims by the providers. The first claims submitted will be rejected until the amount of $210 is reached. Bills received after the recipient amount has been met will be paid by MA.
n Health care expenses used to meet Laurie’s spenddown cannot be used to meet a future spenddown.
Health care expenses are grouped into four different types. For detailed information on each type of health care expense see the individual section of the same name.
The types of health care expenses are defined generally below. Determine the net health care expense to be deducted from the client’s spenddown amount in the order listed:
l H Bills:
H bills are health insurance expenses incurred during the current income certification period. This includes health insurance and Medicare premiums, deductibles, and co-insurance.
l M Bills:
M bills are unpaid health care expenses incurred prior to the certification period. These are old bills the client is still obligated to pay.
l P Bills:
P bills are non-reimbursable or reimbursable health care bills, which are services that are not covered by MA, with dates of service during the certification period.
l R Bills:
R bills are reimbursable MA-covered services received during the current income certification period. MA-covered services include services that MA will cover if the client is eligible on the date of service.
Health Care Expenses Not Allowed
Do not apply the following expenses to the client’s spenddown:
l Health care expenses for MA/GAMC-covered services or for MinnesotaCare-covered services with dates of service during the time the client was on MA, GAMC or MinnesotaCare.
Exception: Unpaid bills for services received outside the managed care health plan network prior to the current certification period and for which client is financially responsible are allowable expenses.
See the following sections for further information on this type of health care expense:
n M Bills.
n Benefit Sets.
l MA or MinnesotaCare payments receiving Federal Financial Participation (FFP) .
l Health care expenses previously used to meet a prior spenddown.
Exception: Health care expenses used to meet a previous spenddown when eligibility was denied for the entire certification period may be used to meet a future spenddown.
l Food, even if it is a cost related to a special diet.
l Housing costs, mortgage payments, taxes, and home owners or renters insurance.
l Utilities, even if required for medical equipment recommended by a physician.
l Items that do not directly benefit the client, such as special equipment requested by the client's personal care attendant or other caretaker.
l Expenses paid by a third party.